Association of Long-Term, New-Onset, and Postsurgical Diabetes With Survival in Patients With Resectable Pancreatic Cancer: A Retrospective Cohort Study.

BACKGROUND: Pancreatic ductal adenocarcinoma (PDAC) has a poor prognosis. Identifying modifiable risk factors, such as diabetes, is crucial. In the context of PDAC diagnosis, diabetes manifests as long-term (LTD), new-onset (NOD), or postsurgical (PSD) phenotypes. The link between these diabetes phenotypes and PDAC survival is debated. MATERIALS AND METHODS: We performed a retrospective study on patients with resectable PDAC who underwent pancreatectomy at Johns Hopkins Hospital from 2003 to 2017. We utilized the National Death Index and electronic medical records to determine vital status. We categorized diabetes as LTD, NOD, or PSD based on the timing of diagnosis relative to pancreatic resection. Using multivariable Cox models, we assessed hazard ratios (HRs) for survival times associated with each phenotype, considering known PDAC prognostic factors. RESULTS: Of 1556 patients, the 5-year survival was 19% (95% CI, 17-21). No significant survival differences were observed between diabetes phenotypes and non-diabetic patients. NOD and PSD presented nonsignificant increased risks of death (aHR: 1.14 [95% CI, 0.8-1.19] and 1.05 [95% CI, 0.89-1.25], respectively). LTD showed no survival difference (aHR, 0.98; 95% CI, 0.99-1.31). CONCLUSIONS: No link was found between diabetes phenotypes and survival in resectable PDAC patients. Comprehensive prospective studies are required to validate these results.

Factors mediating cancer risk in systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) are at an elevated risk for certain cancers compared to the population at large. Cancers seen at higher rates in the SLE population include hematologic malignancies, such as non-Hodgkin lymphoma, and cancers of the lung and thyroid. SLE patients also have a decreased risk for certain malignancies, such as breast cancer, melanoma, and prostate cancer. We review the literature on risk factors for malignancy in patients with SLE and discuss the exogenous and innate factors that are thought to contribute to the unique pattern of cancer risk observed in this patient population. These risk factors are important for providers of SLE patients to understand in order to maintain high clinical suspicion and detect malignancy as soon as possible. Further research is needed to determine the most effective guidelines on counseling patients on cancer screening and prevention.

Stress, mindfulness, and systemic lupus erythematosus: An overview and directions for future research.

Although the pathogenesis of autoimmunity is not fully understood, it is thought to involve genetic, hormonal, immunologic, and environmental factors. Stress has been evaluated as a potential trigger for autoimmunity and disease flares in patients with systemic lupus erythematosus (SLE). The physiologic changes that occur with stress involve numerous catecholamines, hormones, and cytokines that communicate intricately with the immune system. There is some evidence that these systems may be dysregulated in patients with autoimmune disease. Mindfulness-based techniques are practices aimed at mitigating stress response and have been shown to improve quality of life in general population. This review will discuss pathophysiology of chronic stress as it relates to SLE, evidence behind mindfulness-based practices in these patients, and directions for future research.

Systemic Lupus Erythematosus and Common Variable Immunodeficiency.

ABSTRACT: Systemic lupus erythematosus (SLE) and common variable immunodeficiency (CVID) are both conditions defined by immune system dysfunction: one hyperactive, the other hypoactive. Although uncommon, these diseases can coexist in the same individual. This review aims to assess the state of the literature on the relationship between SLE and CVID, particularly when workup for CVID should be considered in individuals with SLE and how CVID in individuals with SLE should be treated.

The Effect of Mycophenolate Mofetil as First-Line Therapy on the Timing of Urine Protein-to-Creatinine Ratio Reduction in Immunosuppressant-Naive Patients With Lupus Nephritis at a Single Center.

BACKGROUND/OBJECTIVES: Early response to immunosuppressive therapy predicts good renal outcome in lupus nephritis (LN). The purpose of this study was to assess the effect of mycophenolate mofetil (MMF) on the timing of urine protein-to-creatinine ratio reaching 200 mg or less after starting MMF as initial therapy for class III, IV, or V in immunosuppressant-naive patients with LN. METHODS: Patients who had a diagnosis of biopsy-proven LN were included in this cohort study. The initial dose of MMF was 1000 mg twice daily. If no improvement, it was increased to 1500 mg twice daily after 1 month. For statistical analysis, exact binomial distribution 95% confidence intervals were calculated. RESULTS: Nine patients were identified. There were 3 patients with class III, 3 with class IV, 1 with class III to V, 1 with class II to V, and 1 with class V lupus nephritis. The majority were African Americans (70%). At baseline, proteinuria ranged between 0.41 and 4 g, and 88% had normal estimated glomerular filtration rate. Forty-four percent of patients reached 0.28 g of proteinuria within 8 weeks of starting MMF (95% confidence interval, 14%-79%), all of which maintained the same level of response and normal estimated glomerular filtration rate at 12 months. Thirty-three percent of patients achieved the American College of Rheumatology complete response at 8 weeks. CONCLUSIONS: This study demonstrates that only a minority of immunosuppressant-naive LN patients achieved the American College of Rheumatology complete response at 8 weeks after initiation of MMF. A rapid decline in the proteinuria to 0.28 g within the first 8 weeks of the treatment correlated strongly with achieving the same level of response at 12 months.

The Cancer Risk Profile of Systemic Lupus Erythematosus Patients.

ABSTRACT: Systemic lupus erythematosus (SLE) patients have a well-established increased risk for cancer. Research from the past 2 decades has identified the specific malignancies that afflict SLE patients at disproportionate rates. Systemic lupus erythematosus patients are at heightened risk for several hematologic malignancies as well as for certain solid tumors, including lung, thyroid, and hepatobiliary cancers. They are at decreased risk for several cancers as well, including prostate and melanoma. Improved understanding of the unique cancer risk profile of SLE patients has led some professional societies to recommend specialized cancer screening and prevention measures for these patients and has enabled clinicians to better serve the SLE patient population.

Broadening learning communities during COVID-19: developing a curricular framework for telemedicine education in neurology.

BACKGROUND: In response to the cancellation of clinical clerkships due to COVID-19, the Johns Hopkins (JH) Neurology Education Team developed a virtual elective to enhance medical students' clinical telemedicine skills and foster community between academic institutions. METHODS: This two-week clinical elective, entitled "Virtual Patient Rounds in Neurology," was administered once in April 2020 and once in May 2020. The curriculum included attending/fellow-led Virtual Rounds, Student Presentations, and Asynchronous Educational Activities. We also developed a new lecture series entitled JHNeuroChats, which consisted of live synchronous lectures presented by JH faculty and Virtual Visiting Professors. Trainees and faculty from outside institutions were invited to participate in the JHNeuroChats. Students and faculty completed pre- and post-elective surveys to assess the educational impact of the elective. Student's t-tests were used to compare scores between pre- and post-elective surveys. RESULTS: Seven JH medical students enrolled in each iteration of the elective, and an additional 337 trainees and faculty, representing 14 different countries, registered for the JHNeuroChats. We hosted 48 unique JHNeuroChats, 32 (66.7%) of which were led by invited Virtual Visiting Professors. At the end of the elective, students reported increased confidence in virtually obtaining a history (P < 0.0001) and performing a telehealth neurological physical exam (P < 0.0001), compared to the start of the course. In addition, faculty members reported increased confidence in teaching clinical medicine virtually, although these findings were not statistically significant (P = 0.15). CONCLUSIONS: Despite the constraints imposed by COVID-19, this virtual Neurology elective increased medical students' confidence in certain telemedicine skills and successfully broadened our learning community to encompass learners from around the world. As virtual medical education becomes more prevalent, it is important that we are intentional in creating opportunities for shared learning across institutions. We believe that this elective can serve as a model for these future educational collaborations.

Health Care in the Age of Mass Incarceration: A Selective Course for Medical Students in Their Preclinical Years.

Introduction: While medical school curricula increasingly address health disparities, content regarding health care for persons impacted by incarceration is a persistent and notable gap. There is a high burden of disease among incarcerated populations, and health care challenges continue postincarceration. We developed a course to introduce medical students to the current landscape of mass incarceration in the US and implications for health and health care delivery to people impacted by this system. Methods: We developed a 3.5-hour elective course taken by 19 first-year medical students in its first year and 20 students in its second. The course utilized lecture, case-based discussion, and guest speaker modalities to introduce students to the history of mass incarceration, health care delivery within the carceral system, and challenges in accessing care during and following incarceration. Results: Students received two surveys after completing the course. In the first, 100% of respondents reported outstanding, excellent, or good levels of satisfaction with various elective components, including organization, learning activities, and student discussion. The second found significant increases in knowledge about mass incarceration and incarceration health issues, in addition to significant increases in interest in advocating or providing health care for incarcerated populations. Discussion: Given current mass incarceration practices, students will encounter patients impacted by this system. This elective course sought to better prepare students to effectively care for these patients. We were limited by time availability, and future directions include incorporating a standardized patient exercise, trauma-informed care principles, and providers working within the carceral system.